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<br />'UHrID DCKVIUtb. Inc.
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<br />03
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<br />Rtlzardohd White Tank Clunure Certifielttlon
<br />- Any seek Complete and submit this page prior W initialing sty cleardng, cutting, dismantling, or Gevvmicn aFa tank aystan that matte the conditions below:
<br />Is destined p y[ aN p_�y held', lw"dM materiel or a bezmdam wwre, Cher is identified gas x nk 55 she.dow [helm oke that
<br />- This _ disposed, re lairtmd m atead to Ii.,
<br />interim swur, to a i irk system or my portion dtereoff,then man, dm daRenime pf sc aMW item pond by rule (PER), or to tank systems regulotcd under a pant of
<br />CCR 666261.6(a)(3)(B} rap metal in 22 CCR 466260.10 amt in Excluded fmm regulation parsaedl l0 22
<br />Refer to 22 CCR 667383.3 and 21 CCR 02672 for disposal mquiremnre rex rank systems,
<br />(Wore: the numbering or the insImetias Follows Ne doh elemerrt oh Dnmrt
<br />arc reed for clac mrbminbers vet see on the UFCF pages. These data element mm�tms
<br />Unified Frogan Dam Dictionary) arand M din su+te m the numbering used in 27 CCR AppenC, dix Int Desires, Semon of the
<br />y.
<br />Flwoe mord ,all pages afyow "t"ree4l. This helps ynur COPA or laced army identify whether the submitla is complete and ff'ay pages em ,operated.
<br />I. FACILITY ID NUaMBER - L m this Wank This number b mel
<br />greed by the LUPA. This is the unique mnnber which idantifia, your f§ciliry.
<br />3. BUSINESS NAME - Errer the fu legal wee orthe business.
<br />740. TANK OWNER NAME- CaaPIOW items 740,744. unless all items am Ne,amc nthe Dusiness Owner
<br />R ADDR
<br />747. TANK OWf7EESS information (llemn111-116) on the Business O[MdOPeteror Identification page
<br />742. TANK OWNER CRY (OBS Pam 2730)Llf
<br />743. TANK OWNER STATE the sang write -SAME AS SITE, acrome
<br />,; this nian
<br />74, TANK OWNERZIP CODE
<br />745. TANK ro NUMBER f-3- EARr ap b Nits owner's tette ID wahen. Thu is a unique number used by the owner m idmtfy the
<br />sank74Rand Ifttmro751.)tharth=Wk-'4rebeingcivwd.cmrMieteaddh/myleopi tOfthi,lagu (Emvaddilionalnnknumhersin
<br />746. CONCENTRATION OF FLAMMABLE VAPOR 1-3 - Fater three interior fla ,t le whet Icvcla for esch tank Ming Glared,
<br />taken It the bp. server, and beaten, of the hnk. (Fm more than oft tank- ener addicarel tank reading, in The and 752, )
<br />747. CONCENTRATION OF OT(YOEN 1.3 - Enter three irectim oxygen levels far each tank hemil dosed, taken of the top, 752, )
<br />and ba ce" of de teak. (roe more Man one lank. enter adsl4imml tank reedinga in 75n and 7S3),
<br />SIGNATURE - Tire b"mmrs owner or o(ficerofthe com peaty who is aedxrdzod m make derision, for the facility and who her Operxrionnl control, shall sign in
<br />the apace Provided
<br />754. CERTIFIER NAME- Enter the fon printed name of the person signing tlb Page.
<br />755. CFR77rFER TITLE- Enter the ritic ofibc person ageing the pogo.
<br />756. CERTIFIER ADDRESS - Enter Ne address orthe person signing the gaga
<br />757. CERTIFIER CRY. Emer the city for the sigmr's addr
<br />758. CERTIFIER RHONE- Fmr the phone mnrdeer Fpr the pers
<br />on signing the page.
<br />759. DATE CERTIFIED - Enter the date thin the document was aged. Enter tint time that the readings were taken,
<br />TIFIER
<br />760, deck -No REPRESENTS LOLL AGENCY - Check "Yes` irfhc Meson aer6fyieg the teak is a reprerenemill of the CUPA, audtaized ogenty, or LIA,
<br />76t. NAME OF LOCAL AGENCY. Etnd the name of Ne laud agency fet esemad by the person certiyirig Ne tank
<br />762. AFFILIATION OF
<br />puss, b tmpFVTNG ifPERSON •Cheeklhexertiftudon lie r orergonisaion which the rxyofier holds or to which
<br />Ne eenlfying posori bdartge, ifnnt a CUPA/ Ltn.
<br />763. TANK FIELD FLAMMABLE OR COMBUSTIBLE MATERIALS -Check -Ya iftM reek held namm,ble or cmnbustible nw, -jals, Check "No if roe
<br />764. MANAGEMENT INSTRUC TONS - Provide Wk msnngenkat man diem m Mc =me dealer. di po j f ditty, ca., in rhl, spec,
<br />IIPCF (32199)
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<br />FO/7nerly DTSC 1249 (6(98)
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